Nadia Habal, MD Presbyterian Hospital of Dallas

1. X-COVER?!? Nadia Habal, MD Presbyterian Hospital of Dallas

2. What is going on? • Goals of Lecture: • How do I make my X-cover list? • How do I identify emergency from non-emergency? • How do I know when I need to go and see the patient? • How do I handle common calls/questions? • When do I need to call my resident???

3. How to make your CareGate list: • Log on to CareGate • Go to Cross Cover • Under “problems”, put one liner about the patient • Then list all important problems and what has been done about them • Under “to do” section put MR number, pt allergies, important meds, anything for X-cover to follow up on

4. Example: • 69 y/o with PCKD and transplant kidney p/w painless hematuria • 1. Renal: pt continues to have hematuria: likely ruptured renal cysts 2/2 PCKD, considering CT abd and MRI results. Also worrying about infx, CA, etc. Continue immunosuppression with Cellcept, prednisone. CMV/EBV by PCR neg. Urology following - possible cystoscopy to r/o bladder source. • 2.Htn: BP well controlled. • 3.Paroxysmal AF: atenolol and Cardizem. Short episode of afib with RVR overnight, with rates of 120s. Continue ASA for prophylaxis. • 4.Hypothyroidism - continue replacement. • 5.Anxiety - continue Ativan. • 6.RA-pain relief. • 7.Insomnia: Ambien. • 8.Wt loss: cancer w/u. • 9.Choledocholithiasis and pancreatic duct stones: ERCP today.

5. Example, continued: • Cross Cover To Do • F/u ERCP results • ALL: NKDA • RX: allopurinol, aspirin, atenolol, Lipitor • … You get the idea!

6. Not Acceptable: • “Patient intubated, sedated, in 1 ICU”… when the pt has been extubated and on the floor for 4 days • Must update room numbers on x-cover list • Must update DNR status • Must put pertinent changes in status (e.g., if a patient went into afib or had GI bleed or is having a procedure) • Must put all pending tests on the list • If someone is really sick, include family contact info in the event of a code or critical change in medical status • YOU MUST UPDATE THE WHOLE LIST EVERYDAY!!!

7. What do I do when I’m called? • We will go through some basics by organ systems today • Future subjects to be covered during Internship 101 lecture series: • ID:      June 30: Pneumonia • CV:     July 3:    Arrhythmias • GI:      July 7:    GI bleeding • Pulm:  July 10:  Sepsis/SIRS • Endo:  July 17:  Hyperglycemic states (DKA and HONC)  • Neuro: July 31: Altered mental status and “Brain Code”

8. NEUROLOGY • Altered Mental Status • Seizures • Cord Compression • Falls • Delirium Tremens

9. Altered Mental Status • Always go to the bedside!!! • Try to redirect patient: drowsy, stuporous, making inappropriate comments? • Is this a new change? How long? • Check for any recent/new medications administered • Check VITALS, alertness/orientation, pupils, nuchal rigidity, heart/lungs/abdomen, strength • Scan recent labs in chart including: cardiac enzymes, electrolytes, +cultures • If labs unavailable, get stat Accucheck, oxygen saturation • Try naloxone (Narcan), usually 0.4-1.2 mg IV, if there is any possibility of opiate OD

10. “Move Stupid” • Metabolic – B12 or thiamine deficiency • Oxygen – hypoxemia is a common cause of confusion Others - including anemia, decreased cerebral blood flow (e.g., low cardiac output), CO poisoning • Vascular – CVA, intracerebral hemorrhage, vasculitis, TTP, DIC, hyperviscosity, hypertensive encephalopathy • Endocrine– hyper/hypoglycemia, hyper/hypothyroidism, high /low cortisol states and Electrolytes – particularly sodium or calcium • Seizures –post–ictal confusion, unresponsive in status epilepticus; also consider Structural problems – lesions with mass effect, hydrocephalus • Tumor, Trauma, or Temperature(either fever or hypothermia) • Uremia – and another disorder, hepatic encephalopathy • Psychiatric – diagnosis of exclusion; ICU psychosis and "sundowning" are common • Infection – any sort, including CNS, systemic, or simple UTI in an elderly patient • Drugs – including intoxication or withdrawal from alcohol, illicit or prescribed drugs

11. Seizures • Go to bedside to determine if patient still actively seizing • Call your resident • Check your ABCs • Place patient in left lateral decubitus position • Immediate Accucheck • If still seizing, give diazepam 2mg/min IV until seizure stops or max of 20mg (alternative: lorazepam 2-4mg IV over 2-5min) • Give thiamine 100 mg IV first, then 1 amp D50 • Load phenytoin 15-20 mg/kg in 3 divided doses at 50 mg/min (usually 1 g total) • Remember, phenytoin is not compatible with glucose-containing solutions or with diazepam; if you have given these meds earlier, you need a second IV! • If still seizing >30min, pt is in status—call Neuro (they can order bedside EEG) • Get Head CT if appropriate and if pt stabilized

12. Cord Compression • Suspect in patients with new weakness or change in sensation (especially if they have a demonstrable level), new bowel/bladder retention or incontinence. • Prognosis is dismal for pts w/no function for >24h. • Prognosis is best for pts with new, incomplete loss (i.e. weakness). • Surgical emergency: call Neurosurgery. • Stabilize the spine: collars for C-spine, Turtle shells (TLSO) for T/L-spine. • Dexamethasone not always indicated (in case of traumatic fracture, for instance). • If tumor, needs immediate radiotherapy.

13. Falls • Go to the bedside!!! • Check mental status • Check vital signs including pulse ox • Check med list • Check blood glucose • Examine pt to ensure no fractures • Thorough neuro check • Check tilt blood pressures if appropriate • If on coumadin/elevated INR—consider head CT to r/o bleed

14. Delirium Tremens (DTs) • Give thiamine 100mg, folate 1mg, MVI • See if patient has alcohol history • Check blood alcohol level • DTs usually occur ~ 3 days after last ingestion • Make sure airway is protected (vomiting risk) • Use Ativan 2mg at a time until pt calm, may need Ativan drip, make sure you do not cause respiratory depression • Monitor in ICU for seizure activity • Always keep electrolytes replaced

15. PULMONARY • Shortness of Breath • Oxygen De-saturations

16. Shortness of Breath • Go to the bedside!!! • Check an oxygen saturation and ABG if indicated • Check CXR if indicated

17. Causes of SOB • Pulmonary: • Pneumonia, pneumothorax, PE, aspiration, bronchospasm, upper airway obstruction, ARDS • Cardiac: • MI/ischemia, CHF, arrhythmia, tamponade • Metabolic: • Acidosis, sepsis • Hematologic: • Anemia, methemoglobinemia • Psychiatric: • Anxiety – common, but a diagnosis of exclusion!

18. Oxygen Desaturations Supplemental Oxygen • Nasal cannula: for mild desats • Face mask/Ventimask: offers up to 55% FIO2 • Non-rebreather: offers up to 100% FIO2 • BIPAP: good for COPD • Start settings at: IPAP 10 and EPAP 5 • IPAP helps overcome work of breathing and helps to change PCO2 • EPAP helps change pO2 • CPAP: good for pulmonary edema, hypercapnea, OSA • Start at 5-7

19. Indications for Intubation • Uncorrectable hypoxemia (pO2 < 70 on 100% O2 NRB) • Hypercapnea (pCO2 > 55) with acidosis (remember that people with COPD often live with pCO2 50–70 +) • Ineffective respiration (max inspiratory force < 25 cm H2O) • Fatigue (RR>35 with increasing pCO2) • Airway protection • Upper airway obstruction

20. Mechanical Ventilation • If patient needs to be intubated, start with mask-ventilation until help from upper level Arrives • Initial settings for Vent: • A/C FIO2 100 Vt 700 Peep 5 (unless increased ICP, then no peep) RR 12 • Check CXR to ensure proper ETT placement (should be around 4cm above the carina) • Check ABG 30 min after pt intubated and adjust settings accordingly

21. CARDIOLOGY • Chest pain • Hypotension • Hypertension • Arrhythmias

22. Chest Pain • Go and see the patient!!! • Why is the patient in house? • Recent procedure? • STAT EKG and compare to old ones • Is the pain cardiac/pulmonary/GI?—from H+P • Vital signs: BP, pulse, SpO2 • If you think it’s cardiac: • Give SL nitroglycerin if pain still present (except if low blood pressure, give morphine instead) • Supplemental oxygen • Aspirin 325 mg

23. Hypotension • Go and see the patient!!! • Repeat Manual BP and HR • Look at recent vitals trends • Look for recent ECHO/ meds pt has been given. • EXAM: • Vitals: orthostatic? tachycardic? • Neuro: AMS • HEENT: dry mucosa? • Neck: flat vs. JVD (=CHF) • Chest: dyspnea, wheezes (?anaphylaxis), crackles (=CHF) • Heart: manual pulse, S3 (CHF) • Ext: cool, clammy, edema

24. Management of Hypotension • If offending med, stop the med! • If volume down/bleeding: give wide open IV NS • Correct hypoxia • Recent steroid use? Adrenal insufficiency • Is there a neuro cause for hypotension? • If appropriate, consider: PE, tamponade, pneumothorax • If fever, consider sepsis—need for empiric antibiotics • If hives and wheezing, consider anaphylaxis—tx with oxygen, epinephrine, Benadryl • Need for pressors? Transfer to ICU!

25. Commonly Used Pressors

26. Hypertension • Is there history of HTN? • Check BP trends • Is patient having pain, anxiety, headache, SOB? • Confirm patient is not post-stroke pt—BP parameters are different: initial goal is BP>180/100 to maintain adequate cerebral perfusion • EXAM: • Manual BP in both arms • Fundoscopic exam: look for papilledema and hemorrhages • Neuro: AMS, focal weakness or paresis • Neck: JVD, stiffness • Lungs: crackles • Cardiac: S3

27. Management of Hypertension • If patient is asymptomatic and exam is WNL: • See if any doses of BP meds were missed; if so, give now • If no doses missed, may give an early dose of current med • Remember, no need to acutely reduce BP unless emergency • So, start a medication that you would have normally picked in this patient as the next agent of choice according to JNC/co-morbidities/allergies

28. Hypertension (continued) URGENCY • SBP>210 or DBP>120 • No end organ damage • OK to treat with PO agents EMERGENCY • SBP>210 or DBP>120 • Acute end organ damage • Treat with IV agents • Decrease MAP by 25% in one hour; then decrease to goal of <160/100 over 2-6 hrs.

29. GI • Nausea/Vomiting • GI Bleed • Constipation • Diarrhea • Acute Abdominal Pain

30. Nausea/Vomiting • Vital signs, blood sugar, recent meds? • Make sure airway is protected • EXAM: abdominal exam, rectal (considering obstruction, pancreatitis, cholecystitis),neuro exam (increased ICP?) • May check KUB • Treatment: • Phenergan 12.5-25mg IV/PR (lower in elderly) • Zofran 4-8mg IV • Reglan 10-20 mg IV (especially if suspect gastroparesis) • If no relief, consider NG tube (especially if suspect bowel obstruction)

31. GI Bleed (to be discussed in detail at a later date): UPPER • Hematemesis, melena • Check vitals • Place NG tube • NPO • Wide open fluids vs. blood • Check H/H serially • If suspect PUD: Protonix drip • If suspect varices: octreotide • Call Resident and GI LOWER • BRBPR, hematochezia • Check vitals • Rectal exam • Wide open fluids if low BP • NPO • Check H/H serially • Transfuse if appropriate • Pain out of proportion? Don’t forget ischemic colitis!

32. Constipation • Very common call! • Check: electrolytes, pain meds, bowel regimen • Check KUB if suspect ileus/obstruction • Rectal exam to check for fecal impaction/mechanical obstruction • Treatment: • If not acute process, can order “laxative of choice” • Fleets enema for immediate relief (unless renal failure b/c high phos—then can order water/soap suds enema) • Lactulose/mag citrate PO if no mechanical obstruction

33. Diarrhea • Check: electrolytes, vitals, meds • Quantify volume, number, description of stools • Labs: fecal leukocytes, stool culture, guaiac, C.diff toxin if recent antibiotic or nursing home resident • Treatment: • Colitis: flagyl 500mg po tid • GI bleed: per GI section • If don’t suspect infection: loperamide initially 4mg then 2mg after each unformed stool up to 16mg daily

34. Acute Abdominal Pain • Go to the bedside!!! • Assess vitals, rapidity of onset, location, quality and severity of pain LOCATION: • Epigastric: gastritis, PUD, pancreatitis, AAA, ischemia • RUQ: gallbladder, hepatitis, hepatic tumor, pneumonia • LUQ: spleen, pneumonia • Peri-umbilical: gastroenteritis, ischemia, infarction, appendix • RLQ: appendix, nephrolithiasis • LLQ: diverticulitis, colitis, nephrolithiasis, IBD • Suprapubic: PID, UTI, ovarian cyst/torsion

35. Acute Abdomen? • Assess severity of pain, rapidity of onset • If acute abdomen suspected, call Surgery • Do you need to do a DRE? • KUB vs. Abdominal Ultrasound vs. CT • Treatment: • Pain management—may use morphine if no contraindication • Remember, if any narcotics are started, use sparingly in elderly, ensure pt on adequate bowel regimen

36. RENAL/ELECTROLYTES • Decreased urine output • Hyperkalemia • Foley catheter problems

37. Decreased Urine Output • Oliguria: <20 cc/hour (<400 cc/day) • Check for volume status, renal failure, accurate I/O, meds • Consider bladder scan • Labs: • UA: WBC (UTI); elevated specific gravity (dehydration); RBC (UTI/urolithiasis); tubular epithelial cells (ATN); WBC casts (interstitial nephritis); Eosinophils (interstitial casts) • Chemistries: BUN/Cr, K, Na

38. Treatment of Decreased UOP Decreased Volume Status: • Bolus 500 cc NS • Repeat if no effect Normal/Increased Volume: • May ask nursing to check bladder scan for residual urine • Check Foley placement • Lasix 20 mg IV

39. Foley Catheter Problems: • Why/when was it placed? • Does the patient still need it? • Confirm no kinks or clamps • Confirm bag is not full • Examine output for blood clots or sediment • Do not force Foley in if giving resistanc: call Urology • Nursing may flush out Foley if it must stay in • The sooner it’s out, the better (when appropriate)

40. Hyperkalemia • Ensure correct value—not hemolysis in lab • Check for renal insufficiency, meds • Check EKG for acute changes, peaked T-waves, PR prolongation followed by loss of P waves, QRS widening

41. Treatment of Hyperkalemia • Immediate Rx (works in minutes): for EKG changes, stabilize myocardium with 1-2 amps calcium gluconate • Temporary Rx (shift K into cells): • 2 amps D50 plus 10 units regular insulin IV: decreases K by 0.5-1.5 mEq/L and lasts several hours • 2 amps NaHCO3: best reserved for non-ESRD patients with severe hyperkalemia and acidosis • B2-agonists: effects similar to insulin/D50 • Long-lasting Elimination: • Kayexalate 30g po (repeat if no BM) or retention enema • NS and Lasix • Dialysis

42. ENDOCRINOLOGY • DKA • HONC (Will be covered in detail at later time)

43. DKA • Identify precipitating factor (e.g., infection, MI, noncompliance with meds) • Check for anion gap • Check for ketones in urine or serum • Give bolus 1 Liter NS, then run IVF at 200 ml/hour if no contraindication • Start insulin drip DKA protocol in ICU (EPIC order) • Check electrolytes every 4 hours and replace as appropriate

44. HONC • Similar to DKA but for Type II diabetes and no ketones • There is also an insulin drip NON-DKA protocol in ICU (EPIC order)

45. ID • Positive Blood Culture • Fever

46. Positive Blood Culture • You get called by the lab because a blood culture has become Positive. • Check if primary team had been waiting on blood culture. • Is the patient very sick/ ICU? • Is the culture “1 out of 2” and/or “coag negative staph”? This is likely a contaminant. • If pt is on abx, make sure appropriate coverage based on culture and sensitivity • If you believe it to be true Positive then give appropriate empiric treatment for organism and likely source of infection/co-morbidities of patient and discuss with primary team in the AM

47. Fever • Has the patient been having fevers? • DDX: infection, inflammation/stress rxn, ETOH withdrawal, drug rxn, transfusion rxn • If the last time cultures were checked >24 hrs ago, then order blood cultures x 2, UA/culture, CXR, respiratory culture if appropriate • If cultures are all negative to date, likely no need to empirically start abx unless a source is apparent and you are treating a specific etiology

48. HEME • Anticoagulation • Blood replacement products

49. Anticoagulation • Appropriate for DVT, PE, Acute Coronary Syndrome • Usually start with low molecular weight heparin—(Lovenox) 1 mg/kg every 12 hours and adjust for renal fxn • If need to turn on/off quickly (e.g., pt going for procedure) use heparin drip—there is a protocol in EPIC • Risk factors for bleeding on heparin: • Surgery, trauma, or stroke within the previous 14 days • History of peptic ulcer disease, GI bleeding or GU bleeding • Platelet count less than 150K • Age > 70 yrs • Hepatic failure, uremia, bleeding diathesis, brain mets

50. Blood Replacement Products • PRBC: One unit should raise Hct 3 points or Hgb 1 g/dl • Platelets: One unit should raise platelet count by 10K; there are usually 6 units per bag ("six-pack") • use when platelets <10-20K in nonbleeding patient. • use when platelets <50K in bleeding pt, pre-op pt, or before a procedure • FFP: contains all factors • use when patient in DIC or liver failure with elevated coags and concomitant bleeding or for needed reversal of INR